Complex Ventral Hernia Repair with Component Separation in High-Risk Patient Population: Classic Surgical Teachings Hold True

Abdominal wall reconstruction (AWR) has grown in both procedural variety and technical complexity over the last decade. Reconstructive techniques for complex ventral hernia repair (VHR) have improved dramatically over the past several years. The rise in the number of reconstructive options and the development of novel mesh technologies has led to an increase in durable hernia repairs with markedly improved surgical site occurrence rates and surgical outcomes.¹ 

The advent of component separation, and its various iterations since inception, has allowed for closure of massive abdominal wall defects during VHR.² Cadaveric studies have demonstrated up to 10 cm of medial advancement of the abdominal musculature following an anterior component separation.³ Posterior component separation with transverse abdominis release (TAR) may provide further advancement for even larger defects.¹ Hernia recurrence rates of 4% to 6% have been reported following TAR with sublay mesh reinforcement,^4,5 extending even to patients with significant comorbidities such as morbid obesity.⁶ Perforator sparing dissection techniques have also been developed in order to preserve blood supply to the fasciocutaneous flaps created during component separation, decreasing postoperative wound complications and skin breakdown.^7,8 

Surgical mesh selection and the plane of mesh deployment also plays a significant role in VHR outcomes. While synthetic options are often preferred in clean surgical wounds, a clean-contaminated or contaminated field may require biological mesh, although significant controversy exists in the current literature regarding mesh selection.² The preferred site for mesh location is an under or sublay position, as lower hernia recurrence and postoperative complication rates have been demonstrated with this method when compared to onlay, inlay, or primary repair without mesh.^1,2

Obesity is the most common comorbidity seen in patients presenting for VHR.⁹ These patients are at an increased risk for both hernia recurrence and postoperative complications following AWR. This had been attributed in part to poor wound healing and decreased oxygen tension seen with excess subcutaneous fat of the abdominal wall.¹⁰ In response, several studies have investigated concurrent panniculectomy following VHR.^11,12 While the results of these studies have varied considerably, the majority endorse that concurrent panniculectomy significantly reduces hernia recurrence rates but increases rates of wound complication.¹¹ 

The variety of surgical options, mesh considerations, concurrent procedures, and frequency of medical comorbidities in the VHR population makes AWR a complex field which requires continued investigation. In this study, a single institution’s experience with complex VHR over a three-year period is presented in order to elucidate the effect of medical comorbidities, reconstructive technique, and concomitant procedures on postoperative complication and hernia recurrence rates.

An Institutional Review Board approved the retrospective chart review, which was performed on all patients who underwent a complex VHR with component separation in combination with AWR with or without panniculectomy from January 2015 to June 2019 at Hackensack University Medical Center in Hackensack, New Jersey. Demographic data were obtained from medical records, including patient’s medical history, smoking status, and hernia-related symptoms. Informed consent was obtained from patients prior to their surgical procedure, which also notes the approval of the use of their deidentified medical and surgical records for the purposes of research. Computed tomography (CT) imaging of the abdomen was reviewed, and hernia size was noted. Pre- and postoperative documentation was also reviewed, and complications were noted along with any subsequent operations performed to address complications or recurrence. Operative reports were reviewed and information regarding mesh use was also recorded. Patients with incomplete medical records were excluded from the study. 

During the time period examined, a total of 40 patients (32.5% male and 67.5% female) met inclusion criteria for the study. The average age at the time of operation was 57 years (range 30 years to 78 years). Seventeen patients had history of a previous hernia repair and 7 had history of more than 1 repair. Medical comorbidities were common in the cohort, the most frequent being obesity (n = 25), hypertension (n = 13), and diabetes mellitus (n = 6). Average American Society of Anesthesiologists (ASA) score was 2.8. Every patient had at least 1 medical comorbidity, with an average number of comorbidities of 1.85. Three patients identified as current smokers, 13 as former smokers, and 24 as non-smokers. (Table 1)

Hernia size ranged from 40 cm² to greater than 400 sq cm². Either anterior or posterior component separation was performed in all cases of AWR (9 posterior, 31 anterior). Mesh was utilized in 90% of cases and only excluded in cases of contamination or history of previous explantation where fascial primary repair was possible. Biologic mesh was used as a bridging mesh in 3 cases, and the remainder of cases involved the use of synthetic mesh. Polypropylene mesh was the synthetic mesh of choice and was commonly deployed in the retrorectus position (n = 27), followed by onlay (n = 6). Concomitant panniculectomy was performed in 28 patients. Hernia repair lasted 3.39 hours on average, with no significant difference in operative time between patients with or without panniculectomy. Twenty-seven patients underwent concurrent panniculectomy at the time of VHR. 

Significant complications occurred in 5 patients, 2 had a postoperative hematoma, 1 had late hernia recurrence, 1 had a postoperative pulmonary embolism (PE), and 1 had a closed loop bowel obstruction. There were 13 surgical site occurrences; 11 of these were in cases where concomitant panniculectomy was performed. Three of the 4 patients who had major complications underwent concomitant panniculectomy at the time of hernia repair. Patients who underwent both procedures were more likely to require a return to the operating room compared to those who did not (51.9% vs 25%). None of the patients expired. Demographic and operative characteristics were compared in patients with a surgical site occurrence or significant complication with patients who did not have a complication. (Table 2)

Five smaller cohorts were created in order to compare patients by body mass index (BMI). Three patients were classified as normal weight (BMI < 25), 11 as overweight ( BMI 25 to 29.9), 10 as Class I obesity (BMI 30 to 34.9), 9 as Class II obesity (BMI 35 to 39.9), and 7 as Class III (BMI >40). (Figure 1) Rates of postoperative complications were found to increase as the obesity classification increased. (Figure 2) The cohorts were subsequently divided into obese (n = 26) and nonobese (n = 14). Rates of postoperative complications were found to be 53.8% in the obese cohort, compared to 21.4% in the nonobese cohort. 

Ventral hernias are a common surgical problem encountered by plastic and reconstructive surgeons. In this study, the authors share their experience with VHR and AWR over a three-year period. By contributing to the existing hernia literature, it is hoped this review may aid in the advancement of the field of AWR, decrease hernia recurrence and complication rates, and improve overall patient outcomes.

Comorbidities

The distribution of comorbid disease was assessed via individual comorbidities in addition to the ASA 5 category physical status classification system. The average ASA class of the patients in the study was 2.8, which reflects the association between requirement of complex VHR and significant systemic disease. The extent of comorbidities in the patient population was more substantial than previous studies assessing concomitant panniculectomy during VHR, as the average ASA class in a study by Smolevitz et al¹² was 2.59. The impact of patient comorbidities is also reflected by the exclusion criteria provided for a randomized prospective study comparing only incisional hernia repair or repair combined with abdominoplasty.¹³ These authors chose to exclude patients with an ASA classification greater than 3 or with cardiopulmonary, hepatic, or renal comorbidities. In a study assessing short-term complications, hernia recurrence, and healthcare utilization by Shubinets et al,¹⁴ the authors concluded that in patients presenting with multiple comorbidities, concomitant panniculectomy should be performed with caution, as these patients are at high risk for early postoperative complications. However, the authors also noted the necessity of optimal repair in these patients, given their increased risk of occurrence. 

Several benefits of panniculectomy in patients with morbid obesity undergoing VHR have been identified in the literature, including better exposure of the defect facilitating component separation and obliteration of dead space.¹⁵ This study adds to the existing literature by reporting the characteristics of a sample with more comorbidities than previous studies. This information is important given the ongoing controversy of concomitant panniculectomy in patients with substantial comorbidities as well as the relative lack of available data. The results are also critical for enhancing preoperative planning and patient risk assessment given the high frequency of comorbid disease and obesity in this patient population. 

Outcomes by Body Mass Index (BMI)

Medical comorbidities are exceedingly common in the VHR population, the most prevalent of which is obesity⁹. Rates of wound complication, returns to the operating room (ROR), and hernia recurrence have been shown to increase significantly with increasing BMI.^16-18 However, several recent studies have indicated that advancements in AWR have led to recurrence rates as low as 6% to 11% in the obese population^6,10. A 2017 comparative study by Giordano et al¹⁰ found no significant difference in hernia recurrence rates among different obesity classes, which the authors largely attribute to component separation techniques. One recurrence was identified in our cohort, however, the ability to draw significant conclusions regarding the impact of BMI on recurrence rates is limited by our sample size.

While hernia recurrence rates approach those of patients who are not obese following a VHR, wound complications and reoperation rates remain significantly higher in patients with excess BMI. In this study, postoperative complication rates increased with increasing obesity classification. Wound complications such as skin necrosis and seroma were more common in patients with BMI in excess of 30 kg/m² and more than doubled in patients with obesity when compared to patients that were not obese. These findings are similar to wound complication and ROR rates found in the existing hernia literature.^10,19,20

Advancements in surgical technique and mesh technologies have helped to maintain the integrity of the abdominal wall following VHR in the obese population, providing a durable hernia repair. However, similar advancements in the prevention of wound complications have yet to emerge. Factors contributing to poor wound outcomes in the obese population include a chronic inflammatory state, decreased oxygen tension of excess subcutaneous fat, and the prevalence of medical comorbidities such as diabetes mellitus.¹¹ The development of epigastric artery perforator sparing fasciocutaneous flaps during dissection may improve blood supply to the skin and subcutaneous tissues in the postoperative period, enhancing wound healing and limiting skin necrosis. Recent studies have shown a decrease in wound complications and ROR rates with utilization of these techniques, although rates remain higher than that of the nonobese population.^6,8 Further investigation is warranted in order to improve wound outcomes and diminish the need for reoperation in a VHR patient with obesity. 

Panniculectomy versus non-panniculectomy

The decision to perform a concurrent panniculectomy during a VHR has been a source of controversy in the literature. A previous study by Shubinets et al¹⁴ demonstrated a substantially lower incidence of hernia recurrence over 2 years of follow-up but reported a higher rate of early complications and greater healthcare expenditures. However, another study reported similar surgical-site occurrence and hernia recurrence rates at long-term follow-up but higher wound morbidity.¹¹ Conversely, Hughes et al²¹ have demonstrated a reduction in the incidence of wound complications and the possibility of hernia recurrence. This was later supported by Reid et al²² who also demonstrated a reduction in the incidence of wound infection.

In this study, 28 patients underwent concurrent panniculectomy at the time of VHR. Fourteen of these patients experienced either a surgical site occurrence (SSO) or postoperative complications in comparison to the 6 patients with complications following VHR alone. Of note, patients who underwent concurrent panniculectomy were more likely to require a return to the operating room for a revision procedure (51.9% vs 25%).

Previous hernia repairs

Prior studies have demonstrated that the number of previous VHRs is an independent risk factor for recurrence, complication rates, and reoperation rates.²³ A study by Smolevitz et al¹² assessing the impact of concomitant panniculectomy demonstrated that, despite having no statistically significant differences in baseline characteristics such as average age, ASA class, gender and operative time, all patients with recurrences had previous hernia repairs. They also noted that those that underwent panniculectomy with a recurrence were considerably heavier than the average of the entire study population (average BMI of 48.2, compared to average BMI of 36.2). In this study, rates of postoperative complication were found to increase with increasing obesity classification. However, it is interesting to note that, when stratified as obese or non-obese, the one recurrence occurred in the non-obese cohort. Amongst the cohort that experienced postoperative SSOs or complications (n = 17), 10 of these patients had had previous hernia repairs. Several of these patients had had up to 4 or 5 attempted repairs, demonstrating the impact of this factor on each patient’s postoperative course. 

Overall complication, reoperation, and recurrence rates

In this study, postoperative SSOs and complications were identified in 14 patients undergoing VHR and panniculectomy, compared to 3 patients with VHR alone. The development of surgical site occurrences is strongly associated with concomitant panniculectomy. ASA class was slightly higher (2.94) in patients with complications when compared to patients without complications (2.69), and 2 of the 3 active smokers developed wound breakdown postoperatively. Among the cohort with postoperative complications, 10 patients had had previous hernia repairs (including several patients with a history of multiple previous attempted repairs). In addition, concomitant panniculectomy was associated with a higher rate of ROR than VHR alone, a finding consistent with previous studies.^12,21 There was also a higher rate of postoperative complications in the obese cohort versus the non-obese cohort (53.8% vs 21.4%), also consistent with other research that has demonstrated a clear association between increased BMI and complication rates.^10,15,23

While this study does provide an extensive retrospective review of high-risk patients who underwent hernia repairs, there are innate limitations to such a chart review, including incomplete documentation and limited follow-up. There were also variations in the types of mesh used and in the surgical techniques utilized among the general surgeons and plastic surgeons in this study. 

Complex hernia repair with component separation can be performed in high-risk patients safely with an acceptable outcome. These procedures can be performed in conjunction with panniculectomy, although this can be associated with an increased risk of postoperative surgical site occurrences such as skin necrosis and seroma. Patient characteristics associated with the development of complications following AWR include obesity, previous hernia repair, and concomitant panniculectomy.

Authors: Jordan N. Halsey MD^a; Nicholas C. Oleck MD^b; Farrah C. Liu MD^c; Sebastian Eid MD^d,f; Frank S. Ciminello MD^e,f

Affiliations: ^aDivision of Plastic Surgery, Department of Surgery, New Jersey Medical School, Rutgers University, Newark, New Jersey; ^bDepartment of Plastic Surgery, Duke University, Durham, North Carolina; ^cDepartment of Plastic Surgery, Stanford University, Palo Alto, California; ^dDepartment of Surgery, Hackensack University Medical Center, Hackensack, New Jersey; ^eDivision of Plastic Surgery, Department of Surgery, Hackensack University Medical Center, Hackensack, New Jersey; ^fDepartment of Surgery, Hackensack Meridian School of Medicine at Seton Hall University, Nutley, New Jersey

Correspondence: Frank Ciminello, MD frank.ciminello@gmail.com

Disclosure: None of the authors have any conflicts of interest to disclose.